I'm a 55-year old woman who had uveitis 3 years ago. The uveitis has been very stable since the initial episode, but steroid eye drops accelerated the formation of cataracts, and I'm contemplating cataract surgery. My dilemma is the type of lens to get.

I've worn glasses since I was six years old, most of that time with bifocals (now progressive lenses), so I'm very used to wearing glasses. The prospect of NOT having to wear glasses is actually little scary for me, although I'm starting to feel excited about it. However, I'm not thrilled at the prospect of having to wear glasses only for near vision, because I don't think I'd like having to carry glasses with me when I'd only have to wear them part of the time.

I'm a software engineer, and I spend a lot of time looking at computer and mobile phone screens. I also tend to stay late at work, which often means driving home in the dark.

My ophthalmologist has suggested Tecnis multi-focal lenses. I have two concerns:

1. They're not covered by insurance, and would cost about $3000 per eye. I'm less concerned about the cost and more concerned about why they're not covered - is it just that insurance companies haven't caught up with the technology or is it that there's some risk in multi-focal lenses that they don't want to cover?

2. I know there are no guarantees, but am I likely to get used to the halos at night? How distracting are the haloes?

I'd appreciate any answers, comments, or suggestions you might have. Thank you!
Original Post
I'm a software engineer, and I spend a lot of time looking at computer and mobile phone screens. I also tend to stay late at work, which often means driving home in the dark.

You are a software engineer and spend a lot of time looking at computer and mobile phone screens and often drive home in the dark! Listen very carefully because this is critical to your decision.

Multifocal IOLs are not covered by insurance because they are considered "premium" devices. They cost a lot more. Why? Because the manufacturer charges more and because there is a huge markup by your surgeon. Are they worth it? Absolutely not. This is not a matter of "waiting for the insurance company to catch up with technology." And there is no litigious risk here on the part of insurance companies.

You have probably experienced using a digital camera. When you are pointing the camera at something in the distance and then bring the camera to bear on something near to you, the camera adjusts the focus. You can hear a little motor in the camera making the focusing change. If you have a $5,000 Nikon camera with an $8,000 lens attached to it, you will also hear a little motor adjusting the focus. WHY DOESN'T NIKON MAKE A LENS THAT CAN FOCUS FAR AWAY AND NEAR WITHOUT HAVING TO ADJUST THE FOCUS? Simple answer: Because it is optically impossible. The picture quality would suffer trying to spread the depth of focus between distance and near (i.e., "reading distance").

Are some people happy with multifocal lenses? Yes. Is everybody happy? No. I have yet to examine a patient who could read as well with a multifocal IOL as patients with monofocal IOLs and reading glasses. In fact, every multifocal lens patient I have examined could see BETTER using reading glasses AFTER surgery. I can tell you, patients who have shelled out $5,000 or $6,000 and find out that a $10 pair of readers off the rack at Walmart helps them read are VERY unhappy.

Forget all the stuff about neural adaptation. Blur is blur. Halos are halos (i.e. spherical aberrations).You may, over time, forget what "really clear" looks like. Multifocal IOLs simply do not and can not provide the crispness of vision of monofocal implants. In fact, one of the contraindications for implanting multifocal IOLs is for patients with macular degeneration. Why? Because patients with macular degeneration already have compromised visual acuity and the MF IOLs will make their vision worse. This implies that patients WITHOUT macular degeneration have so much visual quality to spare that they can afford to lose a little! You are just 55 years of age. You may well live to be 85 or 95 and may well develop macular degeneration. At that point you would dearly welcome the difference in visual quality that monofocal IOLs provide.

Your occupation is visually demanding. Once the IOLs are in, it becomes risky to remove them and the window for IOL exchange is limited to a month or sixth weeks. By the way... You can still wear progressive addition lenses in your glasses. Your Rx does not have to be strictly reading glasses.

I am an optometrist, accustomed to hearing how people see every day, and there is a distinct difference in patients' responses with multifocal IOLs. There is a good chance your surgeon doesn't truly grasp this visual quality difference. A lot of surgeons don't refract patients. Cranking up a 150 watt bulb just above your book is no way to read and certainly no way to prove that multifocals allow sufficient clarity at near.

I know I am offering you a very strong opinion. It's necessary. One more reason why multifocals are expensive: Because everybody throngs to the prospect of never wearing glasses again. It's a big promise. But the fulfillment of that promise is the difference between your expectations and the reality of how light can be bent to a fine focus. Patient expectations all too frequently outrun the laws of physics.

Look in this same section of the bulletin board for what I wrote here: The case against multi-focal IOLs
Will you get used to the halos?


As Dr. Hartzok says, you may forget what clear vision looks like, but that does not compensate for the junk you do see, instead. If you are staring at a monitor or screen all day, you will be miserable. Since most of your reading will be done in that way, you could have dime store readers on your desk and carry another pair with you for the odd times you might need them.

I have single focus IOLs, and I can still get by without readers for most things. For the computer and reading books, I have glasses that reduce the strain and headaches. Carrying them with me is not an issue. I do refuse to have them dangling around my neck, though.

Here's the other little thing they don't tell you. Not everyone gets perfect vision after cataract surgery. If your surgeon's off even a little bit, you will still be wearing glasses after lining his pockets for super-duper lenses that don't perform as promised. Bottom line: Do you feel lucky?
Dear doctor
Despite I am 31 I have already developed a cataract in my right eye.
I am progressively losing visual quality and will likely need a surgery soon. Indeed my occupation is visually demanding.

My eye surgeon has suggested a specific IOL: the Tecnis Symfony.
I understand this is a different technology than the normal multi-focal lenses. They claim it is an extended single focus lens.


Do you have an opinion on them?
Would you still recommend regular OIL?
Cataract surgery at your age is particularly frustrating. We usually don't have a clue as to why one eye develops a cataract many years in advance of the fellow eye, but it happens.

There are two basic issues here. One, using a mono-focal IOL (that provides no specific near vision) will require a reading prescription while the non-operated eye will not. This means that the vision in your two eyes will not be balanced for reading either WITH or WITHOUT reading glasses. The second concern is that using a multifocal IOL will still not provide balanced vision because the image provided by the multifocal IOL at distance and for reading will not precisely match the image in the un-operated eye.

At first glance, it would seem that a multifocal IOL would be the best choice but, frankly, how well your two eyes would work together is unknown. One patient may be quite happy with the arrangement while another may be frustrated with the "non-match" of images.

Could you please provide your present spectacle Rx? Your present glasses prescription is very relevant to your surgical outcome.
I am currently wearing these spectacles

R Sph -4; Cyl -1.5; Axis 180
L Sph -4; Cyl -1.0; Axis 180

To better accomodate for the cataract in my right eye the latest prescription was

R Sph -2.5; Cyl -2.75; Axis 5

This would allow me to improve the a visus from 5/10 to 7/10.

The specialist that I contacted for the cataract surgery suggested to get a ReLex-Smile on the left eye to better balance the vision.
He believes it would be hard to wear glasses after the IOL implantation because the eyes would be unbalanced.
We have had a number of patients here on VSRN with frustrations post-Relex-Smile.

The question of balance is still the issue. Will the image produced by the multi-focal IOL balance well with the image produced by the Relex-Smile procedure?

Multi-focal IOLs are generally contraindicated for patients with macular degeneration. Why? Because the image produced is not as clear as monofocal IOLs and the reduction in correctable vision may prove unsatisfactory to the patient. This is a given with any multifocal IOL. How effective will the focus be for reading with the multifocal? Generally, not as clear as with a monofocal IOL and a reading lens. A lot of your satisfaction will depend on the difficulty of your visual tasks. Small print and extended computer use may be challenging.

The previous paragraph speaks more to the general cataract surgery public. Understandably, at your age, 31, there is every desire to restore your vision without the need for reading glasses. What we cannot know is the subtlety of the difference between the two eyes. However... while 41 may seem like a long way off at your age, ten years will pass and you will need reading glasses as a natural part of aging. Would it be smart to have a monofocal IOL placed in the right eye to solve the cataract problem and the same brand of monofocal IOL placed in your left eye as an elective procedure? Yes. Matching monofocal IOLs would offer you proven image balancing and image quality. This is a highly desirable endpoint. The give back is that you will require reading glasses post-surgery.

While monofocal IOLs would provide the best (and balanced) vision overall, using a multifocal IOL in BOTH eyes will still provide balanced images and a somewhat lower demand for reading glasses

I would hesitate to mix any IOL in the right eye with Relex Smile or other corneal refractive surgery on your left eye. Since you will be paying out of pocket for any procedure done on your left eye, the money would be better invested in an IOL for the left eye that matches the one used in the right eye.
Thank you very much for your recommendations.

From a general point of view I am a bit sceptical of getting a surgery also at my left eye.
Am I right that a reflective lens exchange is even more invasive than a corneal refractive surgery?

Shall I carry out the two RLEs together or there is a way to still benefit from the accommodating capacity of my left eye until I get 40-50?
Relex-Smile is surgery - plastic surgery - on the cornea. And, as with all plastic surgery, outcomes are not always as expected. One could argue that refractive lens exchange is "invasive" but corneal refractive surgery is also invasive; it alters VISION in ways that is less natural than the way IOLs (monofocal) alter vision.

I understand your concern, but mixing Relex with a multifocal IOL is not to be taken lightly. How many patients have had that combination? Have there been any studies of that combination? I doubt it. The benefit of mis-matched procedures is more theoretical than clinical, more conjectural than practical. This is a tough thing at your age. In all cases in my practice and on this BB I take the conservative, long-range view.

You could have the IOL in the right eye and use a contact lens in the left eye. That would preserve the accommodation in the left eye and the balance between the two eyes at distance. Reading, of course, would still be imbalanced.

The IOL surgeries, in the U.S. anyway, are usually done about a month apart.

By the way, how much of a distraction is your right eye vision when wearing glasses? Is it really frustrating for you?
Thank you again for your opinion.
The option of paired OIL seems reasonable but was not mentioned by the doctor I met.
I have a new appointment with him mid august and I will definitively ask his views on it.

Regarding my glasses. Initially I found my right eye quite distracting. Now I guess my brain got used at suppressing that image(I took some tests with my doctor and my stereo vision is very poor).
However, I occasionally suffer from headache. This started some time before the cataract but now it worsened.

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